Processing the Application

7.6.1 Applicant's Burden. The applicant shall have the burden of producing adequate information for a proper evaluation of his experience, background, training and ability, professional ethics, physical health status and, upon request mental health status and emotional stability, and of resolving any doubts about these or any of the other basic qualifications specified in these Bylaws. Each application has the duty to update all information contained in the application during the application process if information supplied by the applicant becomes untrue or incomplete during that period. Each applicant has the duty to supplement information contained in the application as requested by the CEO or his designee.

7.6.2 Verification of Information. The applicant shall deliver a completed application to the applicable Medical Director who shall, in a timely fashion, seek to collect or verify the references, licensure and other qualifications evidence submitted, using primary sources whenever feasible. The applicable Medical Director shall promptly notify the applicant of any failure of others to respond to such collection or verification efforts. After such notice, the applicant shall have the obligation of obtaining responses to requests for information. The applicable Medical Director shall also solicit and receive information concerning the applicant from staff members and, if appropriate, other persons holding staff status, who have

information concerning the applicant's qualifications. Where possible, verification of the applicant's licensure and professional standing in states other than New York is obtained using national clearinghouses established by recognized national professional organizations such as the American Medical Association's Physician Master File and the Federation of State Medical Board's Physician Disciplinary Data Bank, as well as the Federal National Practitioner Data Bank.

7.6.3 Initial Procedure. When collection and verification is accomplished by receipt of responses from all persons or entities so contacted, the application shall be considered complete. The application and all related materials shall then be transmitted to the Credentials/Peer Review Committee. The Committee shall review the application and related documentation for completeness, and may conduct a personal interview with the applicant. Where appropriate, as part of this process, the Committee may require an impartial physical or mental

examination of the applicant and shall require that the results be made available for the Executive Leadership Committee’s consideration. This information taken as a whole, together with other available information relevant to the applicant's qualifications, shall be the professional criteria upon which the Credentials/Peer Review Committee bases their consideration, and such criteria shall be uniformly applied to all applicants.

7.6.4 Credentials/Peer Review Committee Action. The Credentials/Peer Review Committee shall review the application, the related documentation compiled, and such other information available to or obtained by the Committee that may be relevant to consideration of the applicant's qualifications for the staff status and/or clinical privileges requested. The Committee shall have the full resources of the Corporation available to it, as well as the authority to engage outside consultants, if required, to adequately evaluate the applicant’s qualifications. The Credentials/Peer Review Committee shall then transmit a written report, usually

via its minutes, and recommendations as to staff status and clinical privileges and any special conditions to be attached to the appointment, to the Executive Leadership Committee. The Committee may also recommend that the Executive Leadership Committee defer action on the application. The reason for each recommendation shall be concisely stated. Any minority views shall also be reduced to writing, supported by concise statements of reasons and transmitted with the majority report.

7.6.5 Executive Leadership Committee Action. After its receipt of the written report from the Credentials/Peer Review Committee, the Executive Leadership Committee shall meet to review the application and all related documentation, relevant information and recommendations regarding staff status and, if appointment is to be granted, clinical privileges to be granted, and any special conditions to be attached to the appointment. The reason for each

recommendation shall be concisely stated. Any minority views shall also be reduced to writing, supported by statements of reasons, and transmitted with the majority recommendations. The Executive Leadership Committee shall then forward a written report, usually via its minutes, for transmittal to the Board, the application, related documentation, relevant information, and recommendations as to staff status and, if appointment is recommended, as to clinical privileges to be granted and any special conditions to be attached to the appointment. The Sr.

VP of Medical Affairs may, at his discretion, call upon members of the Medical Staff to assist in this process.

7.6.6 Effect of Executive Leadership Committee Action.

(a) Deferral: Action by the Executive Leadership Committee to defer the application for further consideration must be followed up within thirty (30) days with a subsequent favorable or adverse recommendation, or not more than one additional deferral.

(b) Favorable Recommendation: When the recommendation of the

Executive Leadership Committee is favorable to the applicant, the CEO shall promptly forward it, together with the application and all related documentation, to the Board.

(c) Adverse Recommendation: When the recommendation (including those made after deferral) of the Executive Leadership Committee is adverse to the applicant, the Sr. VP of Medical Affairs shall promptly so inform the applicant by Special Notice, and he shall be entitled to the procedural rights as provided in Article IX. An "adverse recommendation" by the Executive Leadership Committee is defined in Section 9.2.1.

7.6.7 Board Action.

(a) On Favorable Executive Leadership Committee Recommendation: The Board shall, in whole or in part, adopt or reject a favorable

recommendation of the Executive Leadership Committee or refer the recommendation back to the Executive Leadership Committee for further consideration, stating the reasons for such referral back and setting a reasonable time limit within which a subsequent recommendation shall be made. If the Board's action is adverse to the applicant, the CEO or the

Sr. VP of Medical Affairs shall promptly so inform the applicant by Special Notice, and he shall be entitled to the procedural rights as provided in Article IX.

(b) Without Benefit of Executive Leadership Committee Recommendation: If the Board does not receive an Executive Leadership Committee

recommendation within the time period specified in section 7.6.11, it may after five days' notice to the Executive Leadership Committee take action on its own initiative. If such action is favorable, it shall become effective as of the decision of the Board. If such action is adverse to the applicant, the CEO or Sr. VP of Medical Affairs shall promptly so inform the

applicant by Special Notice, and he shall be entitled to the procedural rights as provided in Article IX.

(c) After Procedural Rights: In the case of an adverse Executive Leadership Committee recommendation pursuant to Section 7.6.6. (c) or an adverse Board decision pursuant to Section 7.6.7.(a) or (b), the Board shall take final action in the matter only after the applicant has exhausted or has waived his procedural rights as provided in Article IX if the same are applicable to the applicant. Action thus taken shall be the conclusive decision of the Board, except that the Board may defer final determination by referring the matter back for further consideration. Any such referral back shall set a reasonable time limit within which a subsequent

recommendation to the Board shall be made. After receipt of such subsequent recommendation, the Board shall make a final decision.

7.6.8 Denial for Accommodation Reasons. A recommendation by the Executive Leadership Committee, or a decision by the Board, to deny staff status or particular clinical privileges either:

(a) Because the Corporation does not then provide adequate facilities or supportive services for the applicant and his patients, for whatever reason, including but not limited to utilization levels then existing or services not then offered, or

(b) Because of inconsistency with the Corporation’s plans in respect to its development, including the mix of patient care services to be provided, Shall be considered adverse and shall entitle the applicant to the procedural rights as provided in Article IX; provided, however that in a proceeding under Article IX, a determination made without malice by the Board that the

Corporation’s facilities are not adequate or appropriate for the offering or

expansion of a service shall not be subject to challenge with regard to the validity or appropriateness of such determination.

7.6.9 Notice of Final Decision.

(a) Notice of the Board's final decision if favorable to the applicant shall be given to the applicant in the manner determined by the CEO. Notice of the Board’s final decision if unfavorable to the applicant shall by Special Notice

(b) A decision and notice to appoint shall include:

(i) the staff status to which the applicant is appointed;

(ii) the clinical privileges to which he is granted; and (iii) any special conditions attached to the privileges or to

the appointment.

7.6.10 Reapplication after Adverse Appointment Decision. An applicant who has received a final adverse decision regarding appointment shall not be eligible to reapply for a period of two years. Any such reapplication shall be processed as an initial application.

7.6.11 Time Periods for Processing. Action on an individual's application for clinical privileges is withheld until all required information is made available and is verified. Completed applications for staff appointments shall be considered in a timely manner without malice by all individuals and groups required by these Bylaws to act thereon, shall be processed within the time limits specified in any applicable State law, and except for good cause, shall be processed within the time period of 180 days. If all responses required for a complete application are not received at the end of 90 days after being requested, the applicant will be notified about the incomplete responses, and if the required information is not received within 30 days after notification, the application shall be deemed to be rejected due to incompleteness and such action shall be deemed not to be an adverse action against the applicant. The applicable Medical Director shall transmit an application to the Credentials/Peer Review Committee upon completing the information collection and verification tasks. The

Credentials/Peer Review Committee shall act on an application within sixty (60) days after receiving it from the applicable Medical Director. The Executive Leadership Committee shall formulate recommendations to the Board within five (5) days following the regular meeting at which the application was considered.

The Board shall then take action on the application not later than its next regular meeting following receipt of the Executive Leadership Committee’s

recommendation.